Provider Demographics
NPI:1679697411
Name:POTTHARST, ELLEN RHAME (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:RHAME
Last Name:POTTHARST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:ELIZABETH
Other - Last Name:RHAME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:111 E 210TH ST
Mailing Address - Street 2:DEPT OF ANESTHESIOLOGY
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2401
Mailing Address - Country:US
Mailing Address - Phone:718-920-6423
Mailing Address - Fax:718-881-2245
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:DEPT OF ANESTHESIOLOGY
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:718-920-6423
Practice Address - Fax:718-881-2245
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29049207L00000X, 208VP0000X
NY247420207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC290492Medicaid
SC290492Medicaid